25621 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO 'LUMBINL'-EI:RCTRr ^ - Pr:RMrr NO.
APPLICATION/PERMIT r6UMBMO.MPICHANICM.
BUILDING DIVISION BUILDING I'RI3JRC1'IDF;NI'IFICA'I'ION 25821
RUILOMG ADDRESS: SANITARY NO. APPLICATION SUBM ITTAL DATE
w�2s �NI \ �nl'rk LOT#
J D�/'t Wn PHO :. - CONTRAC`TOR'S NAME LIC NO: VC
HiQ/ 1oOk Np CON'fROLN
RCHII?CDENGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
I.ICENSED CONT'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
I hereby (firm that l am licensed under fChat 9(commencin with TOB DESCRIPTION
P ec00 yu pmvirofeso poli g
.100 Section 7000)rf Division of the Business and Professions Cale,and mylicense is in PANELS .
F ��-... farLicense
forcnse Clas effect. UPT02MAMM
W Z W Licensee and Lic.#
m 6 y Dam Contracmr 201-1000 AMPS
'LOy3 ARCHITECTS DECLARATION OVER 1000 AMPS SQ.F'L FLOOR AREA $/SQ.FT.
OZ-0 Iundersmnd my p1.aa,hsll he used.,pabli,neeool, -
Fa+�aF-J SIGNS ELECTRICAL
9K '^
�_l Licensed Professional
L OWNER-BUILDER DECLARATION SPECIAL CIRCUTUMISC.
aOyF ere
1 hby M.dust 1 ran exempt from the Cmance ex License Law for the
u�3orn 6llowingreasoa(Seminn7011.3.Business andProfmionsCode:Anycity.rcoumy TEMP.METF,RORPOLE MST.
(•'.'',o"; which requires a permit m outsmart,61e,,improve,demolish,or repair any marculre
primocitsis...rea.0,u recants;thea licunt fo...ch uo file.si dstalemem POWER DEVICES
rtu,the
PP peen gLo
Cq¢pC that he is licensed pursue.a the provisions n the the Business
License Law(Chapter
ax�o0. 9(corameis exempt
xempt therefrom
and)the Division Sof theeed ixemptio .Any iolaCade) SWIMMING POOL ELECTRIC VAS^•'m^v
W—a recceLeis exemptny applicant
f due recruits subjects
is thedpxemantto civilp penalty
of OUTLETS-SWITCHES-FIXTURES •ODO
(-.z�- Section re tan Eve hundred
dontrs($50rmit subjects the epplicanuoacivil peniltyof `/
�$ t re than fivehundred Rollers($500).' NEW RESIDENTIALELECfR _SQ.FT.
edEo as owner ofthe property,or my employees with wages as their sole compensation, IES '1'YPH CONSTRUCT ION
a3= E oihework,and the stmeture knot intendedoroffered formle(Scc.7044,Business ,
and Profession Cale:The Cottmctors License Law does not apply to an owner of
property whobulldsorimpmves Noreen,and who does such work b0mselforthmugh his
cmplryecs.pmvidahhet sucM1 improvem<nu arenmintendrd proffered fora.le.If, O '.G P RES.UNITS
however,the building or improvement is sold within mayear of emn,letian,the owner- TOTAL:
builder will have We burden of proving dial he did not build or improve far purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ hct he proDhc pre.70y 1..l earla,i, ad Professions
Ctncoeto
onwme the project(Sec.loan
Business and ywhol iosx Caleb The Contractor'. 1
License rawdforsuca ctsnownttof rt hobuildartia he Cont.rcond PERMIT ISSUANCE l !�
PPY pmpc yw pmv
whence Li ,forsuch projects widu.contmcor(,)licenced pursuvtno Ne Convenors ALTER-DRAIN&VENT-
License Law. WATER IIA) PEE SUMMARY
❑ Inn exempt under Sec. ,B&P C lit this reason BACK FLOW PROTECT.DEVICE OMS NO FFGI..
SANITARY YN
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION DRAINS-I1.00R,HOOF,AREA.CONE), SCHOOLTAX Y N
❑ Ihercby affirm thntlhavca<enficam of consenno selGins.......mificae of RECEIP #
WrrkersComriensation lnsurancemecmifiMc�py thermf(See.38W.LabCJ which FIXTURES-PBRTRAP PARK FEE YN
cevcrsnll employee's uailcr,hi,pctnit. GAS-EA.SYSTEM-1 INC.40UTLE'1'S RHCEIPT# -
Policy# BUILDING DIVISIO FRGS
Company GAS-EA.SYSTEM OVER 4IPA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspacion division. GREASE/INDUSTRL WASTE?INTERCEPTOR GRADING FLEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
Mis section need non he completed ifthepsermin is forms,hundred dollars($100) SEWER-SANITARY-STORM M.200FT. ENERGY RI?
orless.)
Icertifythm in due pertormancc of the work fnrwbich thio pemtit is iseueglshnll WATER HEATER W/VENTp?LF.CTR
not employ any person in any menntt so as to become subject .the Workers PAID
Compcnsatiou Lawsof California. Date WATER SYSTEMfUREATING Date Receipt Q z Applicant
z C) NOTICE TO APPLICANT:IL.tier makingthis Certifies.of Exemption,you shuuld NEW RESIDIMIUAL PLMIL SQ.IT. TDYAL:
(~
14 become subject n the Workers Compensation provisims,of the Labor Code,you rant -
� ; forthwith comply with such provision,or this permit sludl lndcemed revoked. BUILDING IEE
Uj z CONSTRUCTION LENDING AGENCY -
.-f Ihereby affirm that there is a construction lending agency for the vertormunce of SEISMIC FEE
U O the work for which his pvmdt is issued(See.3097.Civ.C.) T " ELECTRIC ITE
Lcndds Name w0 PLUMBING FEE F Lmacra Address QTY. MECHANICAL PERMIT FEE
U I certify that I have mud this application and sure that the above information is
>. H7 correct Iagree to comply with all city and county enhancers and state laws relatingm PERMIT ISSUANCE? MI3CIIANICAI.FEE
f'^ U) building construction,and hereby uuthonze representatives oRbis city teener upon the CONSTRUCTION TAX
U 'z ahnvcmeminneJ property for inxpection purposes. ALTERORADDTOMECII.
(Wc)agree to save,indemnify and keep harmless the City of Curitiba.ag.inst
y i 'es,judgmmems.costs andexpeases which me 'n ny weyacerv/l ag1ainst said City AIR HANDLING UNIT(TO 10,IKK)CFM)
n ttnw quenof the gr sting of Obis pe a AIR HANDLING UNI'P(ovaR ho,orlocif )
oygre TApplicnot/Contractorl Date EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS T ERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the applicant or future building occupant store or handle Intruders material ❑IiAUNIT GVE
as defined by the Cupeti no Municipal Cole,Chapter 9.12,and the Health and Safety [HATING l 13R 100.0M BI U)
Cade,Section 25532(07
11 Yea CI No VEPOILA'1'ION FAN(SINGLE RESID)
Will theepplicem offumrehuildingcecupannuuequipmem nrdeviceswhichemit BOILER-COMP 100.010 BTU) I S 4t�CE DKI'R
h J t t defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,40 BTU) LL//
�°i;«it;:,°air eon m raan,n
CIYes ❑No NHW RESIDENTIAL MECH. SQ.FT. OCT 11 199
i
I h.ve mad the[collateral m:ueri.1v orprocmcros ander Chapter 6.95 of the CI)Y Uh
California Health&Safety Code,Sections 25505,25533 and 25534.I understand that tH 1JI]I�/1
if the building does notcurently have a tenant that it is my realsesibility m notify the
vii of the rtyuircmcros which most he met prior m Issuance of.Cerifime of
Occupancy.
Owner or authorized agent Date - TOTAL: ISSUED BY:
OFFICE